5 The Headache Diagnosis and Management Series for the Chiropractor, Part III
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Dynamic Chiropractic – May 17, 1999, Vol. 17, Issue 11

The Headache Diagnosis and Management Series for the Chiropractor, Part III

By Darryl Curl
Editor's note: This is the third article of this series on headache diagnosis and management.
"If I wanted to show a future physician how difficult it is to practice the healing arts, I would give him a headache."

-- Anonymous

Obviously, treating the headache sufferer is neither easy nor completely successful. If it were, articles such as this would not appear in our literature.

Chiropractic is no exception. On the one hand, we have down-to-earth experiences showing that spinal manipulation yields satisfactory results in the treatment of headache. Yet when this empirically derived conclusion is passed through the standard scrutiny of randomized controlled headache trials, we have yet to show that manipulation is significantly helpful to the headache sufferer.

Does This Mean That There Is No Reliable Chiropractic Treatment for Headache?

This is the most important question. If the answer is "yes," then there is no point in dwelling on this subject any further. Essentially, this ends up meaning that the chiropractor randomly offers chiropractic treatment recommendations with a warning to the patient that what is being offered has no likelihood that it will be effective in the management of their headache.

Those who respond with "no" do so in part because of a strong belief that many headache sufferers have experienced reliable results from chiropractic treatment. If this is true, why does this escape the tentacles of confirmatory scientific studies?

The answer lies in the very nature of the headache phenomena. To illustrate this point, let us look at a headache study that simply asks, "Is spinal manipulation effective in the treatment of cervicogenic headache?"

Here, the expectation is that spinal manipulation should be effective as it appears to be particularly well-suited for this type of headache. All one has to do is: gather up chiropractors expert in spinal adjustment; assemble a large sample of confirmed cervicogenic headache sufferers; randomly divide them into a control group and a treatment group; and compare the two groups for the relief of headache symptoms. Basically, this should be a slam dunk in favor of the effectiveness in spinal manipulation ameliorating the symptoms of cervicogenic headache. Right?

Wrong. Studies following this basic design have yet to yield convincing results in favor of spinal manipulation as a reliable treatment for headache. How can this be?

The blame lies in the amorphous trait of the headache phenomena. What does this mean? It means that within a large group of "true" cervicogenic headache subjects, there are several subtypes that are as different from one another as night and day.

This point is best illustrated in the 1997 study by Nilsson et al., who conducted a randomized controlled trial with a blinded observer of a cohort of cervicogenic headache sufferers.1 Their results were seriously undermined by two discoveries.

First, the "manipulation group" decreased the use of analgesics by 36%, but there was no change in the soft-tissue group. Second, the spinal manipulation group also started with an analgesic per day range that was nearly twice as high as the soft tissue group. While the study does have some scientific merit, it is important to point out that the study really appears to illustrate the powerful role of improved headache outcomes due to a greater degree rebound effect from analgesics.

What Does This Mean in Terms of Finding a Reliable Chiropractic Treatment for Headache?

As the science of headache emerges, it is becoming increasingly clear that the key to successful headache management is not based upon a specific treatment (e.g., spinal adjustment, Imitrex, acupuncture). Instead, it is better to compose a "symphony" of treatments based upon a precise diagnosis of the patient's headache.

For example, within the cervicogenic headache subjects discussed earlier, there may also have been those with the analgesic rebound form. For this subtype, there are important and unique treatment needs that go beyond spinal manipulation.

In this author's opinion, subtypes of a given major headache have not been properly incorporated in the chiropractic studies examining the efficacy of spinal adjustment in headache management. These omissions will inevitably lead to erroneous conclusions concerning the value of the spinal adjustment and have undermined the veracity of those few pro-chiropractic studies.

The implications for an accurate headache diagnosis and a correspondingly wise management plan reach far beyond the realm of the researcher. For obvious reasons, the repercussion is greater for the vast number of treating chiropractors who, if their treatments disappoint the headache sufferer, perpetuate and spread the belief that chiropractic is not effective for this common human malady.


Take this simple quiz and keep it close at hand for future articles. The answers to each question will appear in later articles. You may want to clip out each article and save the series for future reference.

Q: Does the disappearance of the headache complaint following therapeutic intervention necessarily mean that the intervention was responsible? Why?

A: Not necessarily. A headache may resolve because, coincidentally, the patient made a change in the daily routine, like not intaking food or drink with aspartame.



1. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther Jun 1997;20(5):326-30.

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